department how they will fill the existing gaps and ensure the new positions they have announced do not become 1,600 empty offices. ultimately what really matters is how long it takes for a veteran to start the first treatment session. what really matters is not abandoning that veteran. i recently saw andrea sawyer whose husband suffers from pssd and depression and she testified about the tremendous difficulties they faced getting him into care. lloyd still faces challenges but he is now getting the care he needs. that is what matters. we cannot let our veterans down, especially when they have shown the courage to stand up and ask for help. i look forward to hearing from v.a., how they intend to address the issues the i.g. found. now more than ever is the time for action and for v.a. to show effective leadership. let the hearing today serve as

an unequivocal call to actions, the department must get this right. in closing, i do want to be clear that while we have discussed a number of problems with the system at large, none of this reflects poorly on v.a.'s providers. i believe i can speak for all of us in thanking v.a.'s many mental health providers for the incredible job they do do. let there be no mistake these individuals are incredibly dedicated to their mission. they choose to work harder than most of their peers often for less lucrative benefits all because they believe in what they do and because they have a deep and unshaking commitment to our veteraning. to all of v.a.'s psychiatrists, psychologists, social workers and other providers and to all the administrative staff that support them, thank you so much for the good job and keep up the good work w that i want to turn it over to senator brown standing in for senator bird today. >> thank you, madam chair. good to be here as the ranking

member and good to be back on the committee serving with you. i want to thank you for holding this very important hearing. somebody i am still serving, i see and hear of these types of situations regularly. $5.9 million billion, the increase they got and out that far do you think we could hire more people to increase the concerns? $5.9 billion, and to read some of the things that we have been reading about the suicidal veteran calling for help, gone unanswered, one more person killing themselves, and the veterans mental health care is delayed, put out by the "washington post," actually yesterday, talking about how the system is being gained by the v.a. and not scheduling and following through with scheduling and providing good opportunity to are these soldiers to get the care and coverage they need. it is mind-boggling.

i understand the delay. i understand there are problems. i understand the claims go over a year. for somebody to call and say, hi, i am thinking of killing myself, do you feel that way right now, well, not right this moment, but i tried to hang myself yesterday, does that count and to be blown off makes absolutely no sense to me at all and so i am glad you're holding this hearing, and i want to continue to look into mental health services. your insights in this committee help perform the oversight to ensure the veterans get the services they need. that's a good thing. one of the several hearings regarding mental health services provided by the v.a, this is another one and last year i remember we did learn about the various serious mental health services that were needed and quite frankly lacking, and i want to just say that today's hearing will focus on vaultieva the service and the care delivered and we will hear from

former v.a. mental health care rick torn teen owe and on going culture problem at the v.a. and i want to thank you for your testimony and pointing out where the loopholes are sought and to hide the fact the facilities are aren't meeting their performance metrics and it is unacceptable for somebody that still serves and sees and speaks regularly with people affected by these very serious ailments, and the gaming of system has to stop, and the i.g. found in the audit and nikon firmed in the testimony that is veterans are not given the opportunity to actually offer a desired date for the next appointment. they were simply told when and where to show up, and no consideration or compassion to address the very real concerns that they have, and scheduling is not the only problem delivering mental health care. even though the v.a. increased staffing by 48%, both the i.g. and nick point out it is under staffed and lacks methodology to

assess the staffing needs and no supplies that just one week after this hearing v.a. announced they're hiring 1,900 additional mental health staffers. that's great. good start. man, what have we been doing up to this point? we need to do it better. we have people's lives depending on these decisions that we're making. it is a good step as i said but how long will it take to actually fill these positions and what happens to that soldier who calls as has been happening with jacob manning and others and we'll hear from community groups that are helping, tom, general tom johns, to help veterans from the conflict manage mental health and i want to thank you, sir, for that effort going above and beyond and help veteran volunteering their time to help fellow soldiers cope with the invisible wounds of war we all know about it and it is a great example of the community coming forward and addressing needs, not currently

being met, so thank you for that. the end, simply hiring more staff and fixing the broken scheduling system will not cure all the issues, but it will certainly take a combination of changes at the facility level and the v.a. office level and the v.a. will use all available resources including fee base care, staffing increases, developing better performance metrics to fix the broken system and i concur with you the individual people there is doing human work but you need more people, more computers, what is it? $5.9 billion somehow go a long way to reference those issues and i am heading upstairs for a quorum and i look forward to everybody's testimony. thank you. >> at this time i would like to introduce the first panel. representing the v.a. is mr. bill shoneheart, deputy under secretary for health operations and management and he is accompanied by dr. antoinette

geist, chief consultant for mental health services and dr. mary shone with the veterans health administration at the department of veterans affairs. from the office of inspector general, dr. david day, inspector jn for health care inspections accompanied by michael shepherd, senior physician in the ig office of health care inspections and also from the office of inspector general we have ms. linda halladay, assistant inspector general for audits and evaluations accompanied by dr. larry rinkmeyer and next we will hear from nick tolon ti no, navy veteran and former health administrator officer in the v.a. and finally hear from the founder and executive director of outdoor odd sigh major general thomas jones. mr. shoneheart, we will begin with your tefrt. we have a lot of answers we need from you. please begin. >> thank you. chairman murray, we appreciate the opportunity today to address

the access to quality of mental health care services to our nation's veterans and we appreciate so much the discussion of a topic that is integral to the well-being and full living out of a fulfilled life of veterans. it is integral to the overall well-being and physical health of a veteran. it is important if there is underlying depression, problem drinking or substance abuse or other medical mental ailments this be diagnosed in order to ensure those who have served our country have the full treatment of something that is so core to their overall well skpk to their ability to also implement the physical health aspects of medication management, staying employed, and the rest which is so important to the quality of

life of a veteran who served this country. it is the sacred mission to ensure this very integral part of our care is well delivered and i appreciate so much your comments regarding the 20,500 providers who on the groundwork so hard every day to serve our nation's veterans in this important mission. we in the written statement i have outlined three areas of improvement and concern but i would like to make first mention that we appreciate so much your leadership, the committee's review and the inspector general's review. this is an important aspect of care and we appreciate all of the assistance and we will be working very closely with the inspector general as we go forward with their report as it relates to the first recommendation i would like to

address and that is that we agree with the inspector general that our appointment measurement system should be revised to include a combination of measures that better capture the overall efforts throughout a course of treatment for a veteran while maintaining flexibility to accommodate a veteran's unique condition and phase of treatment. we must also continue our efforts to strengthen mental health integration into our primary care in order to ensure in the primary care settings that we are assessing mental health needs of our nation's veterans and also be able to address the stigma that's often associated with this that can be discussed in a primary care setting. second point we would like to make announced by the secretary last week we are increasing staff to enhance both the access

to and quality of mental health care by hiring 1,900 additional staff, more than 1,600 of those are mental health clinicians. as i mentioned, this will augment the current implement of 20,500 mental health employees in our system and designed to provide additional staff in our facilities and also designed to increase our staffing of our crisis line which is so integral to the identification and treatment of people who are in crisis as ranking member brown spoke of so eloquently and it is an also an important aspect of increase in that we will be adding additional examiners for compensation and pension examinations. that's an important transition from active duty to veteran status for those who are currently on active duty and for

those who present with new conditions. we have a solemn responsibility to ensure that we increase our staff to ensure that we can handle this volume and in a timely fashion and that we can do this in a way that doesn't erode our capacity to serve our existing patients. i want to emphasize this additional staffing will continue to be evaluating the data and staff model. we are currently piloting this in three visions and this is a work in frogs that will be continually improved as part of our comprehensive approach to ensuring that our facilities have the resources to ensure that we accomplish this mission. the third point i would like to make is in deploying evidence-based therapies to ensure veterans have access to the most effective methods for

ptsd and other mental health ailments, we are making more widespread and improving our training for those who are receiving care and delivering care of evidence-based treatments. we're shifting from a more traditional approach to one with newer treatments and would acknowledge that we have not always communicated these changes as clearly as we might to our nation's veterans so we're redoubling our efforts to improve communication not only to our providers but to our veterans to ensure that these evidence-based therapies are implemented in a way that can be supported by the veteran and fully educated and trained personnel assuring that is delivered. in summary, we thank you again for your encouragement, for your support. this is an important part of care that is fundamental to the

well-being of our nation's veterans and we look forward to those questions. >> ms. halladay. >> madam chairman, members of the committee, thank you for the opportunity to discuss the results of our recent report on veterans access to mental health care services in v.a. facilities we conducted the review at the request of the committee, the v.a. secretary and the house of veterans affairs committee. today i will discuss our efforts to determine how accurately the v.ha records wait times in mental health services for new and established patient appointments. dr. day, the assistant inspector general for health care inspections will address whether the wait time data vha collects is an accurate depiction of the veteran's ability to access those services: we're accompanied by dr. michael

shepherd, a senior physician in the office of health care inspections and larry rinkmeyer, the kansas city office of audit. our review found inaccuracies in data and inconsistent scheduling practices diminished the usability of information needed to fully assess current capacity, resource distribution, and productivity across the v.a. system. in the fiscal year 2011 and the performance accountability year, v.h.a reported 95% of first time patients received a full mental health evaluation within 14 days. we concluded that has no real vul as access to care measure because v.a. measured how long it took to conduct the mental health evaluation, not how long the patient waited to receive that evaluation. we calculated the number of days from the first time initial contact mental health and the

completion of their evaluation. we projected that vha provided only 49% or approximately 184,000 of these evaluations within 14 days of either the veteran's request or referral from mental health care. on average it too 50 days to provide the remaining patient the full evaluation. in fikds year 2011 we determined that v.h.a. completed approximately 168,000 or 64% new patient appointments for treatment within 14 days of their desired date. thus, approximately 94,000 or 36% of the appointments nationwide exceeded 14 days. in comparison, vha data showed that 95% received timely care.

we also projected that vha completed approximately 8.8 million or 88% of the follow-up appointments for treatment within 14 days. thus, approximately 1.2 million or 12% of the appointments nationwide exceeded 14 days. in contrast, vha reported 98% received timely care for treatment. we based our analysis on the dates documented in vha's medical records. however, we have concerns regarding the integrity of the data information because providers told us they used the desired date of care based on their schedule availability. i want to point out that we reported concerns with vha's calculated wait time data in our audits of outpatient scheduling procedures in 2005 and outpatient wait times in 2007. during both audits we found

schedulers were entering an incorrect desired date and our current reviews show these practices continue. for new patient appointments the schedulers frequently stated they used the next available appointment slot as the desired date of appointment for new patients. this practice greatly distorts the actual waiting time for appointments. to illustrate, vha showed 81% or approximately 211,000 new patients received their appointments on their desired appointment date. we found that the veteran could still have waited two to three months for an appointment and vha's data would show a zero day wait time. based on discussions with medical center staff and our review of the data, we contend that it is not plausible to have that many appointments scheduled on the exact day of the patient's desired. i offer the rest of my time to dr. day who will provide the

overall conclusion. thank you. >> dr. day. >> madam chairman, ranking member, members of the committee, it is an honor to testify before you today. i and my staff from the office of health care inspections on a daily basis deal with clinical care issues in v.a., and we know that both the employees and leadership within v.a. strive to provide the highest quality care and despite the subject of this meeting i do believe v.a. provides very high quality health care to its veterans. in fact, with respect to quality metrics, i believe v.a. leads the nation with respect to both the use of data and the publication of that data on the website. with respect to access to care metrics, i believe it is quite a different story. i believe those metrics are flawed, and i believe as our report indicates doctor p.e. tsel will put together a group to get them if line so they do

accurately reflect the business processes that are on going at v.a. i plan to talk about some of the access to care metrics in the private sector, but i think what i would like to make are two different statements after hearing your opening statement, ma'am. the first would be i think v.a. has a number of missions. they have a mission to provide helts care. they have a mission to do research. they have a mission to train individuals who will work in the united states and elsewhere in the health care industry. they have a mission to be available in times of national disaster. i think as individuals out there and hospitals decide how they're going to spend their time, those missions are generally accepted as being equal. there is not a waiting that says the primary mission is the delivery of health care and we will address those assets first as professionals schedule their

time or allocate their time. i think when we have a crisis like we have, that a prioritization of mission, again, stated clearly from top to bottom would allow individuals across the system to rethink how they're spending their time. the second issue i think that's important is to set a standard of productivity. i realize that health care can't be numbers driven. i realize it is a personal interaction between a patient and a provider, but at the same time there has to be some method to determine that you're getting enough work or productivity from the people that are working for you, so i think although v.a. has worked on these issues for a while, i think that there just has to be a clear measurable and in my view productivity standard that is easily relatable to the work done in the private sector by a similar provider, so that

one can decide whether the money spent is actually being effectively used. i think the other issues that brought forward in terms of the kind of access to care standards we could use, i think mr. shoneheart and others understand those and i think we can work with them in order to improve the standards they currently have in place. with that i will end my comments and be happy to answer questions. >> thank you very much. mr. torentino. >> madam chairman, senator brown, members of the committee. as on oe f combat veteran i am hond order to appear to share deep concerns about the administration of v.a.'s mental health care system. my testimony is based on my experience as a mental health administrative offer and service on a committee and work groups and a background in quality management that led to an mba

degree, deep concerns about the manchester, new hampshire, v.a. medical center's failure to provide needed care ultimately led to my increase i guess nation last december. i want to commend this committee for vur vigilant oversight and acknowledge the recent announcement of plans to add positions to the workforce and address problems you helped to uncover, but i want to emphasize that sdashl staff ago loan will not remedy the systemic problems in v.a. management of mental health care. let me be clear. i do not wish to discredit the v.a. or the mental health staff who work diligently to help veterans but for all it strives to do the v.a.'s mental health system is deeply flawed. the system is too open to putting numerical performance goals ahead of mental health care needs. it is susceptible to gaming practices aimed at looking good and too little focus on overseeing the effectiveness of care it promises to provide.

these systemic problems compromise the work of a dedicated staff who fail our veterans. like many v.a. many centers the overriding objective at our facility from top management down was to meet our numbers. meaning to meet our performance measures. the goal was to see as many veterans as possible but not necessarily to provide them the treatment they needed. performance measures are well intended but linked to executive pay and bonuses and as a result create incentive to find loopholes that allow the facility to meet numbers without providing the services. far too often the priority is to meet the measure rather than meet the needs of the veteran. many factors including under staffing make it very difficult to make performance requirements, but administrators don't feel they can acknowledge that and instead as soon as new performance management program manuals were published each year network and facility leadership began planning how to meet those measures. that led to brainstorming, even

with colleagues of mine across the country to find loopholes to gain requirement that is couldn't be met. while i have detailed multiple examples in my full statement, i would like to share two now. several performance measures mandate veterans of mental health treatment be seen within certain timeframes and at manchester where demand was great staffing very limited, the facility director demanded a plan to get veterans seen at any cost. we got the order focus only on the veterans immediate problem. treat it quickly in that appointment, usually with medication, and don't ask further questions about needs because, and i quote, we don't want to know or we'll have to treat it. another directive requires a patient who is actively suicidal or high risk for suicide should be seen at least once per week for four weeks after inpatient discharge. this is too ensure the veterans receiving the intensity of care needed to reduce the risk of readd many i guess and to increase the success of treatment.

instead of providing these high risk patients individual therapy manchester instead created a group for them, a step clinically inappropriate and contrary to the directive's intent. veterans who refused to join the group were often labeled resistant to treatment. the idea of the group therapy could be substituted for individual psycho therapy spread throughout the network. the network mental health executive committee promoted this idea as a so-called best practice. even though it was not at all good clinical practice, it was seen as a good way to meet performance measures. i believe that most v.a. facilities have an under staffed mental health service because the v.a. lacks a methodology to determine what mental health staffing is needed at an individual facility and a miss guided attempt to justify more staff, the head of our mental health service say it needed to be quantity rather than quality. she said and i goat have contact

with as many veterans as we can even if we aren't able to help them. the outcome was the facility continued to enroll a growing be in of veterans, far more than our clinicians could handle and as a result veterans fell through the cracks. tragically there was no effective oversight even to detect the problems we faced. every year they created a central office survey to assess compliance to provide services and each year the network told us we were never to answer the services were not provided. many of our answers were actually changed to say that required services were being provided when they in fact weren't. during my years at manchester other members of the mental health staff and i repeatedly raised concerns with both facility and network leadership regarding practices we believe were unethical or violated v.a. policy. those concerns largely fell on deaf ears. our staff also repeatedly

brought the concerns to our facility ethics committee and to our great frustration they consistently declined to take up these issues because they felt they were clinical matters. the final straw was the medical center's failure to take maningful action upon discovering the mental health clinician was visibly intoxicated while providing care to our veterans. ultimately i could not continue to work at a facility where a veteran's well-being seemed secondary to making the numbers look good. i very much hope the v.a will make real changes to address the systemic problems i sdrooib and there are steps they can take beyond adding staff. i humbly offer the suggestions. they should not rewarding leadership for meeting requirements that are not real measures of effective mental health care. second, the v.a. should institute a more extensive oversight into how care is being provided and how program funding is deployed to ensure the funds go to the programs they are

intended to supplement. finally, i would urge the committee to press the v.a. to develop and implement a very long overdue imperically supported mental health staffing methodology so there is no longer necessary to guess whether 19 more mental health staff will be enough. in closing, i am honored to have had the opportunity to share my experience and assessment of problems and i hope you can help to resolve. i would be very pleased to answer any questions you may have. thank you. >> thank you very much. >> major general johns. >> senator. can you hear me now? >> move the mic up. thank you. >> retired marine, founder and director of outdoor